Question 1

To be sure you have the correct diagnosis code,it is very important to go to the Alphabetic Index first and then to the Tabular List.

Accepted Answer

Going to the Alphabetic Index first is important in order to properly navigate the coding system and ensure an accurate diagnosis code is selected. Then, the Tabular List can be used to confirm the code and ensure any additional rules or guidelines are followed.

Question 2

MATCHING
Match the following with the correct term or definition.
-Have no effect on the main term
A)Tabular List
B)See also
C)Subterms
D)Discharge summary
E)Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers

Accepted Answer

Nonessential modifiers are terms that have no effect on the main term when coding diagnoses. They provide additional description without altering the code assigned to the condition.

Question 3

Which of the following is a basic step in coding?
A)Review the medical record.
B)Identify main term(s)in the Alphabetic Index.
C)Assign codes to the highest level of specificity by verifying in the Tabular List.
D)All of the options are correct.

Accepted Answer

All of the options are basic steps in coding. Reviewing the medical record is important to identify all relevant diagnoses and procedures. Identifying main term(s) in the Alphabetic Index helps to locate the correct code for the diagnosis or procedure in question. Assigning codes to the highest level of specificity by verifying in the Tabular List ensures accurate reporting of the diagnosis or procedure.

Question 4

MATCHING
Match the following with the correct term or definition.
-When a patient displays a symptom that could represent a variety of diagnoses
A)Tabular List
B)See also
C)Subterms
D)Discharge summary
E)Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers

Accepted Answer

Differential diagnosis is when a patient displays a symptom that could represent a variety of diagnoses.

Answer: H
 Chief complaint is the reason why the patient sought medical care.

Answer: I
 The first basic step in coding the principal diagnosis is to identify the reason for the patient's visit, which is generally the chief complaint.

Answer: F
 ER stands for Emergency Room, which is where patients go for emergency medical treatment.

Answer: D
 Discharge summary is a document that outlines the patient's medical history, course of treatment, and recommendations after being discharged from a hospital.

Answer: E
 Coding Clinic is a publication that provides guidance and advice on medical coding.

Answer: A
 Tabular list is a list of codes used to encode diseases, injuries, and other medical diagnoses.

Answer: B
 See also is a cross-reference term used in medical coding to direct the coder to related terms or codes.

Answer: J
 Nonessential modifiers are terms or phrases that are not necessary to describe the patient's condition, but may provide additional detail.

Question 5

The __________,if available,is the first step in the process of record review for code selection.

Accepted Answer

The answer of The __________,if available,is the first step in...

Question 6

The first step in coding the principal diagnosis is to ____.
A)identify the diagnosis and the principal procedure
B)identify main term(s)in the Alphabetic Index
C)review the medical record
D)review any subterms under the main term in the Index

Accepted Answer

The first step in coding the principal diagnosis involves reviewing the medical record to understand the patient's condition, treatments, and outcomes, which then guides the coder in identifying the correct codes.

Question 7

A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.

Accepted Answer

A differential diagnosis is when a patient presents with a symptom that can be related to multiple possible diagnoses, and the clinician must consider and rule out each possibility before making a definitive diagnosis.

Question 8

Exceptions to the general rule that main terms usually identify disease conditions are Z codes.

Accepted Answer

Z codes are used to indicate a reason for a healthcare encounter that is not necessarily a disease, injury, or symptom. Examples include Z codes for routine examinations, screening tests, and immunizations.

Question 9

When evaluating an ER record,a coder should look for the ____.
A)diagnosis
B)chief complaint
C)probable diagnosis
D)differential diagnosis

Accepted Answer

The answer of When evaluating an ER record,a coder should...

Question 10

The main terms usually are nouns and/or disease conditions.

Accepted Answer

Generally, main terms in medical terminology are nouns and/or disease conditions. However, there may be exceptions where other parts of speech can also be main terms, such as verbs or adjectives.

Question 11

In the discharge summary a physician lists the __________ that were evaluated and treated and any procedures that were performed.

Accepted Answer

The answer of In the discharge summary a physician lists...

Question 12

Which of the following is/are a reason(s)why the discharge summary is not the only document from which codes are captured?
A)Coders may not have a discharge summary at the time of coding.
B)If the patient is in the hospital for a long stay,the attending physician will often be focused only on those diagnoses that occurred in the latter part of the stay.
C)Physicians list diagnoses that are not currently being treated and are only in the patient's history.
D)All of the options are correct.

Accepted Answer

All of the options are correct reasons why the discharge summary is not the only document from which codes are captured. Coders may not have a discharge summary at the time of coding, the attending physician may only focus on diagnoses that occurred later in a long hospital stay, and physicians may list diagnoses that are not actively being treated but are in the patient's history.

Question 13

MATCHING
Match the following with the correct term or definition.
-The reason,in the patient's own words,for coming to the hospital
A)Tabular List
B)See also
C)Subterms
D)Discharge summary
E)Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers

Accepted Answer

The chief complaint is the reason for the patient's visit to the hospital.

Answer: D
 The discharge summary is a document that summarizes a patient's hospital stay, including their reason for admission, treatment received, and the results of any diagnostic tests.

Answer: G
 A differential diagnosis is a list of possible conditions or diseases that could be causing a patient's symptoms.

Answer: I
 Determining the principal diagnosis is the first step in coding a patient's medical record.

Answer: J
 Nonessential modifiers are additional terms that provide more detail about a patient's condition but are not necessary for coding purposes.

Note: The other items listed are also related to medical coding and healthcare documentation but do not match the given definitions.

Question 14

MATCHING
Match the following with the correct term or definition.
-Synopsis of the events of a patient's hospital encounter
A)Tabular List
B)See also
C)Subterms
D)Discharge summary
E)Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers

Accepted Answer

Discharge summary refers to the synopsis of the events of a patient's hospital encounter.

Answer: A
 Tabular List is a list of codes that represents different diagnoses, procedures, and related data elements.

Answer: B
 See also is a reference in coding books and manuals to direct the coder to another code or information source.

Answer: F
 ER refers to the Emergency Room where urgent medical care is provided for acute illnesses and injuries.

Answer: G
 Differential diagnosis is a process of determining a diagnosis by comparing and contrasting the clinical findings of the patient.

Answer: H
 Chief complaint refers to the main reason why a patient seeks medical attention.

Answer: I
 The first basic step in coding the principal diagnosis involves reviewing the medical record to identify the reason for hospitalization.

Answer: J
 Nonessential modifiers are additional words or phrases in a diagnosis statement that do not change the meaning of the diagnosis, but can provide additional information.

Note: There is no choice C or E in the given options.

Question 15

The coder should rely solely on the discharge summary to capture all of the diagnoses and procedures that were treated and performed.

Accepted Answer

The coder should review all available medical records (such as progress notes, lab results, radiology reports, etc.) to capture all of the diagnoses and procedures that were treated and performed. The discharge summary may not always include all of the necessary information.

Question 16

The admitting diagnosis is usually a sign or a symptom.

Accepted Answer

The answer of The admitting diagnosis is usually a sign...

Question 17

The main term is ____.
A)always identified in italics
B)a review of the patient's hospital course
C)a term identifying disease conditions or injuries
D)a word found in parentheses that enclose explanatory information that does NOT affect the code

Accepted Answer

The main term is a term that identifies disease conditions or injuries. It is used as the foundation for selecting the correct diagnosis code in medical coding. It is not always identified in italics, may or may not be found in parentheses, and is not the same as a review of the patient's hospital course.

Question 18

A coder must always remember that,once a term is located in the Alphabetic Index,the code must be verified in the Tabular List.

Accepted Answer

This statement is true. It is essential to verify the code selected from the Alphabetic Index in the corresponding Tabular List to ensure accuracy and completeness of the coding process.

Question 19

MATCHING
Match the following with the correct term or definition.
-Emergency Room
A)Tabular List
B)See also
C)Subterms
D)Discharge summary
E)Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers

Accepted Answer

ER stands for Emergency Room.

Answer: I 
 The first basic step in coding the principal diagnosis is selecting it from the Tabular List.

Answer: J 
 Nonessential modifiers are additional words or phrases that do not affect the code assignment.

Answer: D 
 A discharge summary is a document that summarizes the patient's stay in the hospital and includes information about the diagnosis and treatment received.

Answer: G 
 Differential diagnosis is a process of identifying the possible causes of a patient's symptoms.

Answer: H 
 Chief complaint is the main reason why a patient seeks medical attention.

Answer: A 
 The Tabular List is a part of the ICD coding system that contains a list of codes in numerical order.

Answer: E 
 Coding Clinic is a publication that provides guidance on coding and is usually published by the American Hospital Association or the American Health Information Management Association.

Answer: B 
 See also refers to cross-references to other codes or terms that may be related to the one being looked up.

Answer: C 
 Subterms are terms that are listed under the main term in the Index and provide more specific information on the code to be assigned.

Question 20

The main term in "aplastic anemia" is ____.
A)anemia
B)aplasia
C)aplastic
D)none of the above

Accepted Answer

The main term in "aplastic anemia" is "anemia," as it describes the condition being referred to, with "aplastic" serving as a modifier to specify the type of anemia.

Quiz 4: Basic Steps of Coding

To be sure you have the correct diagnosis code,it is very important to go to the Alphabetic Index first and then to the Tabular List.

MATCHING Match the following with the correct term or definition. -Have no effect on the main term

Which of the following is a basic step in coding?

MATCHING Match the following with the correct term or definition. -When a patient displays a symptom that could represent a variety of diagnoses

The __________,if available,is the first step in the process of record review for code selection.

The first step in coding the principal diagnosis is to ____.

A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.

Exceptions to the general rule that main terms usually identify disease conditions are Z codes.

When evaluating an ER record,a coder should look for the ____.

The main terms usually are nouns and/or disease conditions.

In the discharge summary a physician lists the __________ that were evaluated and treated and any procedures that were performed.

Which of the following is/are a reason(s) why the discharge summary is not the only document from which codes are captured?

MATCHING Match the following with the correct term or definition. -The reason,in the patient's own words,for coming to the hospital

MATCHING Match the following with the correct term or definition. -Synopsis of the events of a patient's hospital encounter

The coder should rely solely on the discharge summary to capture all of the diagnoses and procedures that were treated and performed.

The admitting diagnosis is usually a sign or a symptom.

The main term is ____.

A coder must always remember that,once a term is located in the Alphabetic Index,the code must be verified in the Tabular List.

MATCHING Match the following with the correct term or definition. -Emergency Room

The main term in "aplastic anemia" is ____.